Clinical Documentation Specialist: FT, Days

Position Highlights:

• Lifestyle: Sandusky was voted "Best Coastal Small Town in America". You will have the opportunity to enjoy living and working in this growing area along the beautiful shores of Lake Erie.

• Work/life: You will find support to help you manage your personal life while building a career.

• Employee-centric: Tuition reimbursement, loan forgiveness, comprehensive major medical, dental and vision insurance, paid time off, 401(k), health and wellness offerings, monthly employee events, and more.

About Firelands Health:

Our goal at Firelands Health is to be the best & preferred independent healthcare employer for the Sandusky Bay region.

Firelands Health is the area's largest and most comprehensive resource for quality medical care. We are "big enough to care for you, and small enough to care about you". We are locally managed and governed as a not-for-profit healthcare facility, serving the counties of Erie, Ottawa, Sandusky, and Huron, covering a regional service area with over 300,000 residents. Our mission is to provide excellent healthcare, promote community wellness, and improve the lives we serve.

Our Core ACE Values: Attitude: We choose to be positive and inclusive every day. Commitment: We are committed to exceed the expectations of those we serve. Enthusiasm: We will work passionately to make a difference.

What you will do:

• Performs admission/continued stay reviews using Clinical Documentation guidelines within 24-48 hours of admission, and completes concurrent reviews, admission reviews, and discharge reviews daily as needed by insurer.

• Coordinates and communicates ongoing review needs with the Revenue Cycle department.

• Confers with physicians via written or electronic query to clarify information, obtain needed documentation, and to present opportunities to educate regarding the significance of appropriate documentation needed to support the clinical severity of the patient. The education is firmly grounded in research and evidence-based practice.

• Conducts follow-up chart reviews to assure agreed upon information and physician documentation of points of clarification.

• Confers with coding specialists concurrently to ensure appropriate MS-DRG/APR-DRG and completeness of supporting documentation.

• Identify patterns, trends, variances, and opportunities to improve documentation review processes.

• Tracks accurately through verification with final coded MS-DRG/APR-DRG.

• Participates in the day-to-day operation of the Clinical Documentation process.

• Identifies the most appropriate principle diagnosis, CC's & MCC's, including data to accurately reflect severity of the patient (SOI/ROM).

• Works collaboratively with medical, nursing, and ancillary staff to improve the quality of chart documentation and to make sure that the documentation is precise enough to accurately reflect the true clinical picture of the patient following CMS requirements.

• Conducts follow-up chart reviews to assure agreed upon information and physician documentation of points of clarification.

• Insures appropriate DRG, Severity of Illness, and Risk of Mortality assignment.

• Reviews and clarifies clinical issues with coding staff.

• Provide or coordinate education related to compliance, coding, and clinical documentation issues within the healthcare organization. This may include in-person/online education to physicians/additional healthcare staff and rounding with the multidisciplinary healthcare team.

• Conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.

• Collaborates and informs the Manager of Coding of improvement opportunities via referrals.

• Refers quality issues to Manager and/or Physician Advisor as appropriate.

• Assumes all other tasks or responsibilities as assigned by the Manager.

• Participates in educational programs as appropriate and available.

• Attends and participates in monthly department staff meetings.

• Identifies clinical or system/process breakdowns and improvement opportunities and documents according to the PI plan.

• Participates in department performance improvement activities as assigned and attends required training.

• Promote and be involved locally, regionally, or nationally with professional development of the CDS role.

• Participate in CDI-related continuing education activities to maintain certifications and licensures.

• Follows both the Association of Clinical Documentation Integrity Specialists (ACDIS) Code of Ethics and the Ethical Standards for Clinical Documentation Integrity (CDI)

• Professionals as set forth by the American Health Information Management Association (AHIMA).

• Demonstrates service excellence and ACE.

• Successful completion of a ninety (90) day probationary period.

What you will need:

• Registered Nurse with current licensure in the State of Ohio preferred, with a minimum two years acute care experience, preferred experience in coding.

• Certified Clinical Documentation Specialist (or similar credential) with current certification, preferred minimum of two years in clinical documentation improvement.

• Extensive knowledge of complex disease processes, broad clinical experience, and insight into patient needs within the continuum of care.

• Possesses a working knowledge of documentation and coding expectations consistent with regulatory agency and payer requirements.

• Demonstrates the ability to work independently.

• Strong team orientation and communication skills.

• Ability to work effectively with a wide variety of physicians and hospital staff members.

• Ability to problem-solve effectively and manage multiple priorities accurately.

• Ability to meet preassigned metrics as set forth by management.

• Ability to assess, evaluate, and educate physicians and other healthcare professionals on documentation requirements.

• Ability to analyze, correlate and present data.

• Ability to develop and deliver physician education (in-person/on-line) based on current trending identified or industry topics identified.

• Punctual attendance at assigned work location is required.

• Demonstrated ability proficiency in computer skills including Microsoft Office and Excel.

• Ability to work in a safe and efficient manner and maintain an accident free work place, including ability to demonstrate a working knowledge of emergency codes.

• Ability to comply with OSHA regulations and CDC standard and transmission based precaution recommendations and to utilize proper personal protective equipment.

• Ability to comply with provisions of applicable S.D.S. forms.